INSTITUTIONAL PROVIDERS CMS-855A

MEDICARE ENROLLMENT APPLICATION

INSTITUTIONAL PROVIDERS

CMS-855A

SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION. SEE PAGE 5 FOR INFORMATION ON WHERE TO MAIL THIS COMPLETED APPLICATION. SEE SECTION 17 TO FIND A LIST OF THE SUPPORTING DOCUMENTATION THAT MUST BE SUBMITTED WITH THIS APPLICATION.

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved OMB No. 0938-0685

Expires: 09/26

WHO SHOULD SUBMIT THIS APPLICATION

Institutional providers must complete this application to enroll in the Medicare program and receive a Medicare billing number.

Institutional providers can apply for enrollment in the Medicare program or make a change in their enrollment information using either:

? The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or

? The paper CMS-855A enrollment application. Be sure you are using the most current version of the CMS-855A enrollment application.

For additional information regarding the Medicare enrollment process, including Internet-based PECOS, and to get the current version of the CMS-855A, go to Medicare/Provider-Enrollment-and-Certification.

NOTE: Applicants using this application require a Type 2 NPI. See below for more information.

The following health care organizations must complete this application to initiate the enrollment process:

? Community Mental Health Center

? Indian Health Services Facility

? Comprehensive Outpatient Rehabilitation Facility ? Opioid Treatment Program

? Critical Access Hospital

? Organ Procurement Organization

? End-Stage Renal Disease Facility ? Federally Qualified Health Center ? Histocompatibility Laboratory ? Home Health Agency ? Hospice ? Hospital

? Outpatient Physical Therapy/Occupational Therapy/ Speech Pathology Services

? Religious Non-Medical Health Care Institution ? Rural Emergency Hospital ? Rural Health Clinic ? Skilled Nursing Facility

NOTE: Opioid Treatment Programs may complete the CMS-855A or CMS-855B enrollment application.

NOTE: Per Section 125 of the Consolidated Appropriations Act of 2021 (CAA) an action plan is required to be submitted with the enrollment application.

If your provider type is not listed above, contact your designated Medicare Administrative Contractor (MAC) before you submit this application.

Complete and submit this application if you are a health care organization that plans to bill Medicare and you are:

? An institutional organization that will bill for Medicare Part A services (e.g., hospitals, Community Mental Health Centers, Skilled Nursing Facilities).

? Enrolling in the Medicare program for the first time with this MAC under this tax identification number.

? Currently enrolled in Medicare but have a new Tax Identification Number. If you are reporting a change to your current Medicare enrollment to your tax identification number, you must complete a new application.

? Currently enrolled in Medicare and need to enroll in another MAC's jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another MAC).

? Revalidating your Medicare enrollment. CMS may require you to submit or update your enrollment information. The MAC will notify you when it is time for you to revalidate your enrollment information. Do not submit a revalidation application until you have been contacted by the MAC.

? Previously enrolled in Medicare and you need to reactivate your Medicare billing number to resume billing. Prior to being reactivated, you must meet all current requirements for your supplier type before reactivation may occur.

? Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you have added or changed a practice location). Changes must be reported in accordance with the timeframes established in 42 C.F.R. section 424.516.

NOTE: Ownership changes that do not qualify as CHOWs, acquisitions/mergers, or consolidations should be reported. For instance, assume that a business entity's stock is owned by A, B, and C. A sells his stock to D. While this is an ownership change, it is generally not a formal CHOW under 42 C.F.R. 489.18. Thus, the ownership change from A to D should be reported as a change of information, not a CHOW. If you have any questions on whether an ownership change should be reported as a CHOW or a change of information, contact your MAC or CMS location.

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? Reporting a Change of Ownership (CHOW), Acquisition/Merger or Consolidation. ? A CHOW typically occurs when a Medicare provider has been purchased (or leased) by another organization. The CHOW results in the transfer of the old owner's Medicare Identification Number and provider agreement (including any outstanding Medicare debt of the old owner) to the new owner. The regulatory citation for CHOWs can be found at 42 C.F.R. section 489.18. If the purchaser (or lessee) elects not to accept a transfer of the provider agreement, the old agreement should be terminated and the purchaser or lessee is considered a new applicant and must initially enroll in Medicare. ? An acquisition/merger occurs when a currently enrolled Medicare provider is purchasing or has been purchased by another enrolled provider. Only the purchaser's Medicare Identification Number and Tax Identification Number remain. Acquisitions/mergers are different from CHOWs. In the case of an acquisition/merger, the seller/former owner's Medicare Identification Number dissolves. In a CHOW, the seller/former owner's provider number typically remains intact and is transferred to the new owner. ? A consolidation occurs when two or more enrolled Medicare providers consolidate to form a new business entity. Consolidations are different from acquisitions/mergers. In an acquisition/merger, two entities combine but the Medicare Identification Number and Tax Identification Number (TIN) of the purchasing entity remain intact. In a consolidation, the TINs and Medicare Identification Numbers of the consolidating entities dissolve and a new TIN and Medicare Identification Number are assigned to the new, consolidated entity.

Because of the various situations in which a CHOW, acquisition/merger, or consolidation can occur, it is recommended that the provider contact its MAC if it is unsure as to whether such a transaction has occurred. The provider should also review the applicable federal regulation at 42 C.F.R. ? 489.18 for additional guidance. Note that the transactions described above as CHOWs, acquisition/mergers, and consolidations are each considered a type of potential change of ownership under 42 C.F.R. ? 489.18 (e.g., a consolidation can constitute a 42 C.F.R. ? 489.18 CHOW). They are separated into three categories on the application strictly to help the provider understand the precise data that must be reported.

? Voluntarily terminating your Medicare billing privileges. A provider should voluntarily terminate its Medicare enrollment when it: ? Will no longer be rendering services to Medicare patients, or ? Is planning to cease (or has ceased) operations.

NOTE: Submit separate CMS-855A enrollment applications if the types of providers for which this application is being submitted are separately recognized provider types with different rules regarding Medicare participation. For example, if a provider functions as both a hospital and an end-stage renal disease (ESRD) facility, the provider must complete two separate enrollment applications (CMS-855A)--one for the hospital and one for the ESRD facility. If a hospital performs multiple types of services, only one enrollment application (CMS-855A) is required. To illustrate, a hospital that has a swing-bed unit need only submit one enrollment application (CMS-855A). This is because the provider is operating as a single provider type--a hospital--that happens to have a distinct part furnishing different/additional services.

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BILLING NUMBER AND NATIONAL PROVIDER IDENTIFIER INFORMATION

The Provider Transaction Access Number (PTAN), often referred to as a Medicare Provider Number, Medicare Billing Number, CMS Certification Number (CCN), or Medicare "legacy" number, is a generic term for any number other than the National Provider Identifier (NPI) that is used by a provider to bill the Medicare program.

The National Provider Identifier (NPI) is the standard unique health identifier for health care providers and suppliers and is assigned by the National Plan and Provider Enumeration System (NPPES). Medicare healthcare providers, except organ procurement organizations, must obtain an NPI prior to enrolling in Medicare or before submitting a change to your existing Medicare enrollment information. Applying for an NPI is a process separate from Medicare enrollment. As an organizational health care provider, it is your responsibility to determine if you have "subparts." A subpart is a component of an organization that furnishes healthcare and is not itself a legal entity. If you do have subparts, you must determine if they should obtain their own unique NPIs. Before you complete this enrollment application, you need to make those determinations and obtain NPI(s) accordingly. For more information about subparts, visit Regulations-and-Guidance/Administrative-Simplification/ NationalProvIdentStand/implementation to view the "Medicare Expectations Subparts Paper." To obtain an NPI, you may apply online at nppes.cms.. For more information about NPI enumeration, visit Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/apply.

NOTE: The Legal Business Name (LBN) and Tax Identification Number (TIN) that you furnish in section 2B1 must be the same LBN and TIN you used to obtain your NPI. Once this information is entered into PECOS from this application, your LBN, TIN and NPI must match exactly in both the Medicare Provider Enrollment Chain and Ownership System (PECOS) and the National Plan and Provider Enumeration System (NPPES).

Organizational Health Care Providers (Entity Type 2): Organizational health care providers are eligible for an Entity Type 2 NPI (Organizations). Organizational health care providers may have a single employee or thousands of employees. Examples of organizational providers include hospitals, home health agencies, groups/clinics, nursing homes, ambulance companies, health care provider corporations formed by groups/ individuals, and single member LLCs with an EIN, but do not include individual health care providers.

INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION

All information on this form is required with the exception of those fields specifically marked as "optional." Any field marked as optional is not required to be completed nor does it need to be updated or reported as a "change of information" as required in 42 C.F.R. section 424.516. However, it is highly recommended that if reported, these fields be kept up-to-date. ? This form must be typed. It may not be handwritten. ? When necessary to report additional information, copy and complete the applicable section as needed. ? Attach all required supporting documentation. ? Keep a copy of your completed Medicare enrollment package for your records.

TIPS TO AVOID DELAYS IN YOUR ENROLLMENT

To avoid delays in the enrollment process, you should: ? Complete all required sections, as shown in section 1. ? Ensure that the Legal Business Name shown in section 2B1 matches the name on the tax documents. ? Ensure that the correspondence address shown in section 2C is the provider's address. ? Enter your NPI in the applicable section(s). ? Include the Electronic Funds Transfer (EFT) Authorization Agreement (when applicable) with your

enrollment application with a voided check or bank letter. ? Sign and date section 15. ? Ensure all supporting documents are sent to your designated MAC. ? Pay the required application fee (via pecos.cms.pecos/feePaymentWelcome.do) upon initial

enrollment, the addition of a new practice location, and revalidation PRIOR to completing and submitting this application to your MAC.

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OBTAINING MEDICARE APPROVAL

The usual process for becoming a certified Medicare provider is as follows: 1. The applicant completes and submits a CMS-855A enrollment application and all supporting

documentation to its MAC. 2. The MAC reviews the application and makes a recommendation for approval or denial to the State survey

agency, with a copy to CMS. 3. The State agency or approved accreditation organization conducts a survey. Based on the survey results,

the State agency makes a recommendation for approval or denial (a certification of compliance or noncompliance) to CMS. Certain provider types may elect voluntary accreditation by a CMS-recognized accrediting organization in lieu of a State survey. 4. The MAC conducts a second contractor review, as needed, to verify that a provider continues to meet the enrollment requirements prior to granting Medicare billing privileges. 5. CMS makes the final decision regarding program eligibility. If approved, the provider must typically sign a provider agreement.

ADDITIONAL INFORMATION

? You may visit our website to learn more about the enrollment process via the Internet-Based PECOS at: Medicare/Provider-Enrollment-and-Certification/Become-a-Medicare-Provider-or-Supplier. Also, all of the CMS-855 applications are located on the CMS webpage: Medicare/CMS-Forms/CMS-Forms/ CMS-Forms-List. Simply enter "855" in the "Filter On:" box on this page and only the application forms will be displayed to choose from.

? The MAC may request, at any time during the enrollment process, additional documentation to support or validate information reported on the application. You are responsible for providing this documentation within 30 days of the request per 42 C.F.R. section 424.525(a)(1).

? The information you provide on this application will not be shared. It is protected under 5 U.S.C. section 552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application for the Privacy Act Statement.

ACRONYMS COMMONLY USED IN THIS APPLICATION

? C.F.R: Code of Federal Regulations ? EFT: Electronic Funds Transfer ? EIN: Employer Identification Number ? IHS: Indian Health Service ? IRS: Internal Revenue Service ? LBN: Legal Business Name ? LLC: Limited Liability Company ? MAC: Medicare Administrative Contractor ? NPI: National Provider Identifier ? NPPES: National Plan and Provider Enumeration System ? OTP: Opioid Treatment Program ? PTAN: Provider Transaction Access Number also referred to as the Medicare Identification Number ? SSN: Social Security Number ? TIN: Tax Identification Number

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